This case study summarises the Commissioner's consideration of a
case involving the care provided by a general practitioner (the GP)
and a general paediatrician (the paediatrician) to a young
asthmatic boy with a cashew nut allergy. Sadly, the boy died
following an anaphylactic reaction to cashew nuts. This summary
concludes by outlining learning opportunities associated with the
case.

Background

The boy had a history of reactions to cashew nuts, which was
first noted in September 2004 (at age 4) when he reacted to cereal
and developed an itchy skin rash. He was treated successfully with
Phenergan (an antihistamine).

In October 2004, a blood test was arranged through his GP which
confirmed the presence of IgE antibodies to a group of four nuts,
including cashew nuts. In December 2004, the GP referred the boy to
a paediatrician who had seen him previously on other matters,
including asthma which had developed in 2001. In January 2005, the
boy had a further reaction - a sore stomach with no rash - to a
sandwich containing a spread/dressing containing cashew nut.

The paediatrician reported back to the GP in March 2005 that he
had discussed allergy types with the boy's mother and that the boy
did not, on that occasion, seem to have had either an anaphylactic
or anaphylactoid reaction. The option of an EpiPen®
(auto-adrenaline delivery device) was discussed, but since he had
responded well to Phenergan the paediatrician felt that continuing
with that would be a satisfactory option.

Further reaction

In April 2005, the boy ate some dip containing traces of cashew
nut and suffered a more pronounced type of reaction: an
asthmatic-type cough, welts, snuffly nose and runny eyes, and he
complained of difficulty breathing. He was given two doses of
Phenergan and settled two hours later.

His mother arranged a further appointment with the paediatrician
in August 2005. The paediatrician's report stated "I explained to
[his mother] that [the boy] seems to have had an anaphylactoid type
reaction and therefore I would have a low threshold to having an
EpiPen which only needs to be used in cases of anaphylaxis".

The paediatrician did not arrange any further follow-up, but
reviewed him again in July and August 2007 in relation to his
deteriorating asthma. The GP advised that between August 2005 and
June 2009 there was no consultation at which it became necessary to
discuss the allergy in the context of his ongoing asthma
management.

The boy's mother said that, based on the discussion with the
paediatrician, she gained the impression that the reaction was
anaphylactoid, and that this was not as serious as anaphylactic
reaction and "was the second in a three stage continuum". She
advised that she did not understand that her son's condition could
be life-threatening. She acknowledged that there was a discussion
about the use of an EpiPen®, and her impression was that the
paediatrician did not consider an EpiPen® necessary. Consequently,
it was decided to continue treating any reaction the boy suffered
with Phenergan and prednisolone. The GP recorded in her notes in
August 2005 under "long term classifications" that the boy had a
food allergy, being an anaphylactoid type reaction to nuts. After
2005, his parents tried to avoid their son being exposed to
cashews, and he had no known exposure to cashews between April 2005
and June 2009.

The boy was at a friend's home in June 2009. The parent caring
for the children gave them cashew nuts. They had not been told of
the boy's allergy. The boy did not recognise the nuts, and reacted
to them. His parents collected him and took him to a nearby medical
centre. The boy walked into the medical centre unaided. Adrenalin
was administered and centre staff spoke to the Emergency Department
(ED) at the local (tertiary) hospital. However, his condition then
quickly worsened and an ambulance was called. Further adrenalin was
given and an oral airway was inserted as the ambulance arrived. A
back-up ambulance was called to assist with his airway. This
ambulance transported him to hospital where, sadly, he died.

Coroner's report

In November 2009, the Coroner issued his findings that the boy
died when he had an anaphylactic reaction to the ingestion of
cashew nuts, causing status asthmaticus. The initial report from
the pathologist stated that status asthmaticus was attributable to
cashew nut sensitivity. This opinion was reviewed following
submissions made by the boy's parents, and included information
from another paediatrician. The submissions raised issues about the
cause of death. The pathologist amended the cause of death to
status asthmaticus attributable to cashew nut anaphylactic
hypersensitivity.

The second paediatrician also commented on the availability of
EpiPens® in New Zealand. He referred to a 2006 article in the New
Zealand Medical Journal which suggested that New Zealand had fallen
behind the UK, North America and Australia in the provision of
adrenaline auto-injectors, such as EpiPens®.

The Coroner commented on the expense involved with the purchase
of EpiPens® in New Zealand. While the Coroner was unable to say if
the availability and use of an EpiPen® would have prevented the
boy's death, he recommended that Pharmac review its decision not to
fund the provision of adrenaline auto-injectors as a treatment for
individuals at risk of anaphylaxis.

Complaint

Paediatrician

The boy's parents complained to HDC about their son's care. They
raised concerns about the quality of information provided about his
nut allergy, resulting reactions, and links between asthma and nut
allergy. They were also concerned about the lack of planned
follow-up or review when their son was discharged from paediatric
overview. They felt that the confusion that arose could have been
prevented if there were more formal links with an immunology
service.

GP

The parents also had some concerns relating to the GP's care.
These revolved around: the review system; the GP's role in
reviewing/updating the management of a child's nut allergies;
whether the allergy was taken into account when considering
treatment for asthma; and whether the impact of deteriorating
asthma on the allergy management/risk was considered.

Wider issues

His parents also raised some wider issues, such as that the
health authorities did not provide national standards or consistent
national delivery of advice and treatment on food allergies. They
were concerned about the availability of immunology services and
direct links between paediatricians and immunologists. They
considered that advice on when to prescribe and administer
adrenaline auto-injectors like EpiPens® was unclear and
inconsistent across the country.

The paediatrician's response

The paediatrician indicated that he discussed the use of an
EpiPen® with the mother in 2005. His view was that as the boy did
not have a history of cashew anaphylaxis he did not need to carry
an EpiPen®. Due to his change in response to cashews, he used the
term "anaphylactoid" and considered that the boy needed
prednisolone as well as Phenergan at that point. He advised that he
discussed these options with the boy's mother and he considers that
the management prescribed was consistent with relevant guidelines.
The paediatrician said he commented "I would have a low threshold
to giving [him] an EpiPen® if anyone felt he needed one (see ASCIA
guidelines 'may be recommended')".[1]

The paediatrician said he explained to the boy's mother that an
anaphylactic reaction is a severe life threatening reaction in
which there is acute respiratory and/or cardiovascular compromise
and "the term 'anaphylactoid' reaction is widely used … to describe
a 'pseudoallergic' reaction which has some features of anaphylaxis
but not the same consequences".

The paediatrician is unable to recall, but does not think he
would have said that the boy's reaction would change to an
anaphylaxis. He noted that, apart from the risk of anaphylaxis
being remote, one of the reasons EpiPens® are not routinely given
is that they have a shelf life of about a year, meaning regular
renewal and expense. They are also light and temperature sensitive.
In some cases, such as when there is significant ingestion of the
antigen, there is no certainty that they will be of assistance.

The paediatrician also responded that he emphasised keeping the
boy's asthma well controlled and he discussed asthma treatment such
as inhaler technique to aid control. He recalls during the final
consultation, in August 2007, asking about the allergy and that he
was reassured that the boy had been kept off cashews and had no
further reactions. At that stage, his asthma was well
controlled.

The paediatrician outlined that his preference when discussing
the seriousness of such conditions is to not specifically tell a
parent that asthma or allergy could be fatal, which could cause
unnecessary distress. He focuses on reinforcing the appropriate
management of the conditions.

GP's response

The GP responded that after the boy was discharged by the
paediatrician in August 2005, her GP role was to provide
prescriptions, ensure the notes recorded the diagnosis, and
reinforce any management plans instigated by the paediatrician. If
any recurrent symptoms indicated a review of allergies was required
then she would refer the patient back to the paediatrician.

The GP advised that her software review system does not
automatically remind a clinician about allergy reviews. Any review
required would need to be loaded manually into "Recalls". She said
that she did not do this, because she was strongly guided by the
paediatrician's letters of March and August 2005. The letters
indicated to her that thorough discussions were had with the boy's
mother about allergies, allergy reaction types, and treatment
options. She considered that the letters reflected that a joint
decision had been made about the boy continuing to use Phenergan
and prednisolone.

The GP said that the deterioration in the boy's asthma appeared
to her to be multi-factorial. She was not aware of there being any
relationship between the severity of a nut allergy and worsening
asthma. Any causal connection with a nut allergy she considered
would be more within the sphere of a sub-specialist
paediatrician.

Expert advice - key points

HDC requested preliminary expert advice from Dr Caroline
Corkill, GP, and Dr Roger Tuck, General Paediatrician, in relation
to the care provided by the paediatrician and the GP.

Dr Corkill remarked that the parents took their son to see
doctors appropriately and that the GP appeared to monitor and treat
his conditions appropriately.

Dr Corkill considered that the doctors caring for the boy had
diagnosed his asthma and were treating it appropriately. Signs and
symptoms were measured and recorded, and suitable medication was
used to treat the asthma. Appropriate tests were requested and the
notes record the GP was seeking specialist opinion appropriately.
The notes showed reasonable care of his allergies and that the GP
did well to identify the cashew allergy when he was a
four-year-old. Dr Corkill commented that consideration of allergies
is relevant when reviewing deteriorating asthma and that it may
well be that such consideration is best given in the context of a
paediatric or immunologic specialist review. She is not aware of
any formal requirement or recommendation for monitoring of
allergies, and that GPs in her peer review group do not routinely
monitor or follow up patients regarding allergies unless requested
or driven by the patient's problems. Dr Corkill also advised that
she believes it is a shared responsibility of the patient/family,
GP and specialist to follow up on any health problems.

Dr Tuck considered that the paediatrician's approach was
consistent with that expected of a paediatrician in 2005 and he had
provided an appropriate general paediatric consultation. Dr Tuck
noted that cashew nut allergy was well recognised in 2005, and the
high risk association with atopic asthma was first identified in
the literature that year. The risk association has become
increasingly apparent in recent times. Dr Tuck stated that the
definition of anaphylaxis is now agreed internationally and the
term "anaphylactoid" is discouraged, and that many reactions
previously described as anaphylactoid are in fact IgE mediated and
therefore anaphylactic.[2]

Dr Tuck also commented:

Food allergy is an emerging problem and GPs and general
paediatricians are now much more widely educated than they were in
2005;

Educational material and web-based guidelines are more widely
available;

Surveillance and management of long-term conditions should
happen in a partnership of patients/parents, general practitioners,
and specialists - involving provision of contemporary information
and encouraging a personal interest in keeping up to date with
trends;

The boy's long-term conditions should have been under ongoing
review. Surveillance and management of this should happen in a
partnership of patients/parents, GPs, and specialists;

Adrenaline delivery systems (like EpiPens®) are costly, which
is an issue for those who are not well resourced. Families using
such devices require support and education, which is variable
around the country; and

International literature suggests that these devices are not
always prescribed appropriately, are often not available to the
patient when most needed and are not without serious side effects,
including death, if inappropriately used.

Overall, the Commissioner was satisfied that the decisions made,
and the care provided by the GP and the paediatrician was
reasonable in the circumstances and at the time. However, the
Commissioner was mindful of Dr Tuck's comment that the boy's
long-term conditions, including his nut allergy, should have been
under ongoing review. The Commissioner suggested to both the GP and
the paediatrician that they reflect on Dr Tuck's comment in respect
of their future practice, and keep abreast of ongoing developments
in this field - including the issue of health professionals working
more closely together, with families, to ensure quality and
continuity of services and co-operative monitoring of long-term
conditions.

Learning opportunities

There are ongoing developments in relation to food allergies in
children. HDC's experts along with appropriate clinicians and
professionals working in this field recently provided HDC with the
following information:

Dedicated allergy clinics have been developed within some
general paediatric services around New Zealand. However, currently
there is only a specialist paediatric allergy/clinical immunology
service situated at Starship Hospital, and no national service.
Starship specialists undertake outreach clinics in allergy and
clinical immunology in three DHBs (Bay of Plenty, Southland and
Waikato), and accept referrals at Starship from paediatricians
around New Zealand as needed;

Many DHBs endeavour to increase awareness of managing allergies
appropriately across the health sector by updating public health
nurses on a yearly basis, networking with other nurses, and working
with paediatricians to disseminate information to GPs via the
medical website Healthpoint (www.healthpoint.co.nz) or via GP/paediatrician
liaison;

Public health nurses are generally involved in school education
about allergies and adrenaline devices, but generally not in
preschools. However, in some areas, public health nurses are
involved in both pre-school and school education;

Allergy NZ has been supported by ADHB to run a number of
educational workshops for early childhood services concerning
prevention, recognition and management of food allergic reactions.
Allergy NZ also supports training for groups and services in some
other centres in conjunction with volunteer health
professionals;

The Paediatric Society of New Zealand, led by paediatric
allergy and immunology specialists, has formed a special interest
group (Allergy SIG) which has a paediatric representative from most
DHBs to support the upskilling of paediatricians. The Allergy SIG
is developing a draft consensus statement for diagnosis and
management of food allergy in New Zealand children;

A New Zealand Clinical Immunology and Allergy Group (NZCIAG)
comprises most of the immunologists, allergists, and clinical nurse
specialists working in this area. NZCIAG has developed guidelines,
which to date, have mainly been clinical immunology related, and
are often used to review best care options for a range of rare and
problematic conditions. Consideration of guidelines on other topics
such as food allergy has been proposed;

The first ASCIA allergy action plans were released in 2003,
along with the ASCIA guideline for EpiPen® prescription. This
information was disseminated to paediatricians around New Zealand.
Updates about new versions of the action plans have also been
disseminated;

The ASCIA website (http://www.allergy.org.au) contains information
on the recognition and management of allergies and anaphylaxis. In
2009, ASCIA started to develop online e-learning modules initially
for schools and preschools, and subsequently for health
professionals;

Allergy NZ have a booklet "Letting go" which helps families
develop strategies for discussing risk assessment. ASCIA has
published a document for use in schools and preschools[3];

The EpiPen® prescription guideline was developed in 2003, and
it remains the general framework for recommendation of
self-injectable adrenaline.

Since April 2011, AnaPen® has come on to the New Zealand
market. The devices are currently unfunded by Pharmac;

Allergy NZ liaise with public health nurses who identify
children enrolling at school who have been diagnosed by a general
practitioner with a food allergy and advised to get on
auto-injector however can not afford it, and/or do not have an
action plan on treating anaphylaxis. Allergy NZ Guidelines state
that children enrolling in school who have been advised to get an
auto-injector should have an ASCIA anaphylaxis action plan signed
by their doctor;

Allergy NZ is currently updating guidelines for schools to
incorporate the Anapen® and the EpiPen2® which is due in New
Zealand shortly; and have disseminated information on these new
auto-injectors and their related Action Plans through its database
of health professionals, including the public health nurses who
work with families and schools. The Action Plans can also be
downloaded from its website www.allergy.org.nz;

Allergy New Zealand promotes the use of Action Plans through
its communications relating to anaphylaxis. This includes: "Allergy
& Anaphylaxis Guidelines for Early Childhood Services &
Schools" (2006); a 2009 pamphlet on anaphylaxis; information on its
website; and through its magazine "Allergy Today"; and

Best Practice Advocacy Centre (BPAC) NZ, Better Medicine, Issue
18, December 2008, includes the article The Management of
Anaphylaxis in Primary Care featuring a section on long term
management, education about avoiding triggers, and risk reduction.
See: http://www.bpac.org.nz/magazine/2008/december/contents.asp

The boy's parents requested that this case study highlight the
need for parents, as well as care providers, to keep abreast of
developments and to seek regular review of their child's food
allergy, given that medical research and knowledge, factual
contexts, and risk factors can change over time.

Following discussion with the boy's parents, HDC formulated this
case study to place on the HDC website for educational purposes,
and brought the case to the attention of the Royal New Zealand
College of General Practitioners (RNZCGP), the Paediatric Society,
Coronial Services, the NZCIAG, the Ministry of Health, Pharmac, the
National Health Board, and the Health Quality and Safety
Commission.

[2] Today the
Australasian Society of Clinical Immunology and Allergy (ASCIA)
defines anaphylaxis as a rapidly evolving generalised multi-system
allergic reaction characterised by one or more symptoms or signs of
respiratory and/or cardiovascular involvement and involvement of
other systems such as the skin and/or the gastrointestinal
tract.